HomeMy Public PortalAbout6133-6135 GOLDEN WEST AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 76A642D
CF 808 (2-80)
APPLICATION FOR PERMIT
CE 80
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C. `�� � COUNTY OF LOS ANGELES BUI LDING AND SAFETY
Policy No. Company
l WP$IV5SNe FOR APPLICANT TO FILL IN CONNECTION DATA
❑ Cer ified copy is here y furnishe
BUILDING STATION DEPTH
❑ Certified copy is filed with th build' inspection ADDRESS
j UPPER
e r e / LOCALITY �1 MANHOLE REFERENCE LOWER
Dat p '8zApplica 7 NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEM TION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. TO P.L.
COMPENSATION INSURANCEP.C. NO.
OWNERkEr-EX, CO. IMP. NO. JOB NO.
MAIL
(This section need not be completed if the work involved ADDRESSTRUNK PERMIT NO. ROAD PERMIT NO.
by the permit is for one hundred dollars ($100) or less.) a
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. ND, DATE
CITL EL. NO. , O
I certify that in the performance of the work for which this LEGAL
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING Cr
so as to become subject to the Workers' Compensation Laws. Q
BLOCK Ll TRACT STATE ENCROACHMENT
Date Applicant II NOW NO. OON LOT F BLDGS. PERMIT NO. W
K
NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT �
Exemption, you should become subject to the Workers' USE OF CHARGES Z Cn
Compensation provisions of the Labor Code, you must forth- BUILDINGS e
with comply with such provisions or this permit shall be CONTRACTI �1 CONNECTION CHARGE FEE
deemed revoked.
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
DISTRICT NO. GROUP MAP PROCESSED By
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the BUST- CITY TEL. NO. BK PG
ness and Professions Code, and my license is in full force and STATE CLALIC. ASS ;7;7
effect. LICENSE NO. I�W CLASS
NO. DESCRIPTION OF WORK FEE
rigZ HOUSE SEWER CONNECTING TO FINAL VALIDATION
License Number Lic.Class PUBLIC SEWER DATE
�_ �� Z SEPTIC TANK, SEEPAGE PIT OR
n! tracto Date �� ' PITS AND/OR DRAINFIELD FINAL f+
HOUSE SEWER CONNECTING TO �r..
BY
Elan
DISPOSAL SYSTEM �'� fI"`t��`� -•
am x pt the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR tf
lice sed architect or a registered professional engineer WORK TO HOUSE SEWER •
acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD p
EXTN.,CESSPOOL,DRYWELL,MANHOLE
InesS and PIOfeSSIOn$Code). I�
ALTER, REPAIR OR ABANDON HOUSE J
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date aaf
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERSPermit E
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE
ness and Professions Code):
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 2146 2 1 A
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
El1, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 # 0 0 0 0 1 Q
7044, Business and Professions Code). OWNER oR
OWNERS AG ENT 2 01- 40,00
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency o.0 0 4 0, O O L6
for the performance of the work for which this permit is • I
issued(Sec. 3097,Civ.C.). 06 2 8-'—8.2
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the abo a-men .oned opert for i spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si a ure of Permitt Date